Wisconsin health care groups work with the feds on Obamacare

While Gov. Scott Walker's administration continues to give Obamacare the cold shoulder, groups outside of state government are stepping in to work with federal officials implementing the law in Wisconsin.

"We are hitting a real pivotal turning point in implementation right now," says Sara Eskrich, who works for two advocacy groups that are part of the Wisconsin Access Network - a loose affiliation of activists, providers and insurance carriers that formed earlier this year to make sure their voices were heard as the Affordable Care Act was put in place.

There's no time to waste, Eskrich and others say.

The law requires virtually everyone by 2014 to have health insurance, either through work, through a government program like Medicaid or Medicare, or by purchasing a policy. For that reason, a statewide health insurance marketplace - called a health insurance exchange - must be up and running a year from now. The exchange will enable individuals without employer-based coverage, as well as smaller employers with up to 100 workers, to shop for health benefit plans that the law's supporters say will cost less than individual and small group policies typically do now.

"It gives them the power they don't have right now to purchase affordable insurance that covers their needs," says Kenneth Munson, director of the federal Health and Human Services Chicago regional office, which covers Wisconsin.

Because Walker last month announced that the state would forgo the option of establishing Wisconsin's health exchange, the federal government is taking on that job directly. Munson says consumers would not notice a difference between an exchange run by the state, the federal government or through a state-federal partnership - a third option that was available to the state.

But establishing the exchange is only one of three major tasks involved in putting the program in place.

In order to ease the requirement that everyone purchase health insurance, the law provides subsidies for those who can't afford the premiums and expands Medicaid for low-income people. The state will ultimately also have to decide whether it will agree to the Medicaid expansion in exchange for federal funding.

In addition, Wisconsin, like every state, will have to settle on a standard for "Essential Health Benefits" - that is, what every insurer must offer if it wants to be included in the state exchange.

"This is going to have an effect on what kinds of plans are provided in the individual and small group insurance market in the state," says Donna Friedsam, health policy programs director at the University of Wisconsin Population Health Institute.

Although each is a separate agenda item, says Eskrich, "we have to think of them as simultaneous conversations working together to create full implementation of the Affordable Care Act."

Meaningful control

Walker, like many other Republican governors, has always opposed the federal health reform law and a year ago shut down all state activity preparing for its implementation. When he dumped the job of setting up an exchange on the federal government, he complained that either a state-run exchange or the alternative of a state-federal partnership would tie the state's hands while draining its wallet.

"No matter which option is chosen, Wisconsin taxpayers will not have meaningful control over the health care policies and services sold to Wisconsin residents," Walker explained when announcing his decision. "If the state option is chosen, however, Wisconsinites face risk from a federal mandate lacking long-term guaranteed funding."

Asked about the criticism, Health and Human Services spokeswoman Maril Alsup told Isthmus her agency would "prefer not to engage in an indirect debate," but said that it "will continue to work very hard to provide states with the greatest amount of flexibility in the establishment of their exchange."

Friedsam disputes Walker's contention that taxpayers would have little control if the state created its own exchange. "Many states do believe that there is an opportunity for them to tailor the exchange to their preferences," she says. But because of the state's hands-off policy, she adds, "there has not been any kind of public process" to discuss implementation in Wisconsin.

Eskrich agrees: "Other states have been working on this for more than six months now. Unfortunately Wisconsin was not proactive on this on the state level."

To fill the vacuum, several organizations teamed up to form the Wisconsin Access Network. The network is coordinated by four groups: the Wisconsin Alliance for Women's Health, the Wisconsin Council on Children and Families, the state chapter of the American Cancer Society and the Wisconsin Primary Health Care Association, which represents community health clinics around the state. Eskrich works with the network as a joint employee of both the Wisconsin Council on Children and Families and the Wisconsin Alliance for Women's Health.

Many more groups have taken part in the network, she says, representing chronic-disease patients, other health care providers, preventive care organizations, health insurance carriers, Native American health centers and advocates for people with disabilities.

The Access Network has had discussions with officials from the Department of Health and Human Services, including regional director Munson, who was a deputy director for the Wisconsin Department of Health Services under Gov. Jim Doyle.

The network is currently marshaling members to meet a Dec. 26 deadline for comments to the federal government about the regulations governing the Essential Health Benefits package.

Already, HHS has proposed (PDF) as the state's "benchmark" plan the "Choice Plus Definity HSA" plan from UnitedHealthcare Insurance Co., which includes a Health Savings Account. UnitedHealthcare, part of UnitedHealth Services Corp., based in Minnesota, has generally ranked as the largest health insurance provider in Wisconsin in recent years, with about one-third of the market.

To make sure the benchmark plan is adequate, says Eskrich, "we're trying to look at it and figure out where there needs to be supplementation."

Additional coverage

One change that some in the Wisconsin Access Network would like to see is the addition of coverage for habilitation, which is not included in the benchmark plan.

Unlike rehabilitation - helping people recover functions they have lost to an injury or illness - habilitation means treatment to help people improve or maintain functions that were below par to begin with. This could include, for instance, therapy to improve motor skills for someone with cerebral palsy.

"That's something that hasn't always been included in the private insurance market," says Eskrich. If it becomes available under health reform, advocates believe that people who qualify could be moved from Medicaid to a traditional employer-based health plan, provided their workplace has one.

Eskrich says that the state Office of the Commissioner of Insurance has taken part in Access Network meetings and that agency officials "were very open to working together" in negotiating with the federal government. OCI spokesman J.P. Wieske did not respond to two email inquiries for comment.

While health care activists had hoped for a state exchange, Eskrich says that once the federal one is operating, there may be an option for converting it to local control.

"I think in the future we still have a lot of potential to take it back in the state and take on more and more functions," she says. "I hope we recognize the opportunity there and take advantage of it."